Western Pa. agencies take on all aspects of aging

Jennyann Sorco, 57 of Pitcairn kisses her father, James Bauccio 83 also of Pitcairn at Bauccio's home, Tuesday, November 13, 2012. Sorco and her brothers are the primary caregivers for her father.
Andrew Russell | Tribune-Review

Jennyann Sorco, 57 of Pitcairn poses with her father, James Bauccio 83 also of Pitcairn at Bauccio's home, Tuesday, November 13, 2012. Sorco and her brothers are the primary caregivers for her father.
Andrew Russell | Tribune-Review

Jennyann Sorco, 57 of Pitcairn helps her father, James Bauccio 83 also of Pitcairn out of his wheelchair at Bauccio's home, Tuesday, November 13, 2012. Sorco and her brothers are the primary caregivers for her father.
Andrew Russell | Tribune-Review

Helping people help themselves

Cheryl Poling has a note taped to her computer that says: “You're going to transfer this skill or you're going to move in with them.”

Her joke reminds her that she must teach patients skills, or she'll have to move in with them.

“We encourage them to call the doctors themselves,” said Poling, a health coach at Canonsburg General Hospital, part of the West Penn Allegheny Health System. “We tell them to don't go to the hospital unnecessarily if it's something you can do with just a phone call.”

Poling is among coaches in the region who assist patients after hospitalization to avoid repeat trips.

Poling recalls one patient she assisted who had retained 12 pounds of water weight because of congestive heart failure.

She was able to help him call his doctor and have his medication adjusted. Within two days, he was back to his normal weight. Ordinarily, he would've gone back to the hospital.

“He said, ‘I'm as stubborn as a mule, but you got to me,'” said Poling. “He was very thankful.”

To reach Agencies on Aging, call 412-350-5460 in Allegheny County; 724-830-4444 in Westmoreland County; or 724-489-8080 in Fayette, Greene and Washington counties.

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She needs three of herself: one to work full-time; one to spend time with her husband, daughter and grandchildren; and one to care for her frail father.

“It comes down to whoever needs help the most,” said Sorco, 57, of Pitcairn. She and her family share the responsibility of caring for her father, James Bauccio, 83, who suffered a brain aneurysm in 1997.

With the help of an aide provided through the Allegheny County Area Agency on Aging, a part of the Department of Human Services, Sorco and her two brothers have been able to keep their father in his home.

Agencies across Western Pennsylvania work to help people like Bauccio who want to stay in their residences but need constant care. The concept is one of the goals outlined in Pennsylvania's State Plan on Aging for 2012-16, which was released last month.

Much of the state plan's initiatives are in line with efforts the agencies have been making for years, administrators say, and the state goals are meant to help them build on existing strategies. The state's 52 Area Agencies on Aging develop their own four-year plans to complement the state plan while focusing on their local communities.

“There are ways to improve, especially with the elderly population increasing,” said Beth Herold, administrator of the Butler County Agency on Aging. “We want to make sure we're providing the right services at the right time to enable people to stay in their homes as long as possible.”

The number of people 65 and older grew by more than 40,000 in Pennsylvania from 2000 to 2010, according to the Census.

Having an approved state plan is a requirement for the state to receive Older Americans Act funding, said Department of Aging Deputy Secretary David Gingerich. Local funding is influenced by the plan, but not dictated by it, he said.

Keeping seniors in their desired environment — in most cases, their homes — is the “biggest part of what we do,” said Mary Phan-Gruber, deputy administrator of the Allegheny County Area Agency on Aging.

“The bulk of services are targeted at extending independent living,” she said.

Bauccio's aide is provided through the Family Caregiver Support Program, which provides financial aid and stress relief for about 500 Allegheny County residents caring for older adults.

Bauccio relies on a wheelchair. He is paralyzed on his right side, cannot see out of his left eye and has no hearing in his left ear. For years, Sorco's mother, Giovanna, served as her husband's caregiver. But when she died of a heart attack in 2005 at age 75, the family took over.

“My mother always said, ‘I pray Dad goes before me,'” Sorco said, through tears. Her mother did not want her children to have to disrupt their lives to help him.

But the family is happy to do whatever it takes to care for their father, Sorco said.

“We want to repay what he's done for us.”

Area Agencies on Aging also focus on ways to curb factors affecting health care costs.

In February, local agencies received funding from the Center for Medicare and Medicaid Services — the federal agency that administers Medicare, Medicaid and the State Children's Health Insurance Program — for community-care transitions programs. Under these programs, health coaches work with families to make the move from hospital or nursing facilities to home as smooth as possible. Agencies are reimbursed per service.

The program's goal is to reduce the rate of readmissions to hospitals for high-risk, Medicare-eligible individuals.

“It's not good for the patient, and it does help contribute to the high cost of health care,” said Leslie Grenfell, executive director of the Southwestern Pennsylvania Area Agency on Aging, serving Fayette, Greene and Washington counties.

The Southwestern Pennsylvania agency, along with the Westmoreland agency, is partnering with Monongahela Valley, Canonsburg General, The Washington Hospital and Excela Health Westmoreland, Latrobe and Frick hospitals for the transition program. The Allegheny County agency works with West Penn Allegheny Health System's Allegheny General, Forbes Regional and Allegheny Valley hospitals and Ohio Valley General Hospital and Jefferson Regional Medical Center.

Staff trained as health coaches work with individuals in a number of ways upon discharge. They meet with clients during home visits and make follow-up phone calls. They focus on medication management. The 22 coaches will serve more than 6,000 fee-for-service beneficiaries annually, administrators project.

“Sometimes, there might be a change in medication upon discharge,” said Grenfell. “Something might have been added or deleted, and they're not necessarily sure. There might not have been a caregiver there at the time, they might not have paid attention or forgot.”

The coaches review discharge papers and develop a booklet for patients that contains their health history and information on their medications.

Readmission most often happens because a patient has missed follow-up appointments with their physician, Grenfell said. Coaches help schedule appointments and coordinate transportation.

Coaches watch for signs of recurring illness. For example, if a patient with congestive heart failure gains weight or has leg or ankle swelling, the coach will make a doctor's appointment.

Preliminary results of the pilot program in the Southwest and Westmoreland agencies' territories showed an 11 percent readmission rate among patients. The national average for readmissions is about 18 percent. Seventy-four percent of patients reported being more aware and active in their own health care.

“It's really to improve the health care of the patient by empowering them,” said Ray DuCoeur, administrator of the Westmoreland agency.

Rachel Weaver is a staff writer for Trib Total Media. She can be reached at 412-320-7948 or rweaver@tribweb.com.

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